“Thinking Time”: Doctor Envies Curlers

Until I sat down to watch the Olympics this winter, I hadn’t heard of curling. When I surveyed the Internet, I was surprised to learn that each curling team is allocated a certain amount of official “Thinking Time”—to confer, to look at the options, to consider their strategy. And all this is in order to aim a granite rock down an icy path where the stakes are low; the worst that can happen is losing the game.

I’m jealous. As a seasoned primary care doctor, I’m acutely aware that my profession provides no such time, despite the fact that primary care is fundamentally an intellectual field. Our “procedure” is purely cognitive; our skill set is exactly that—thinking. And in healthcare, the stakes are high.

Much has been written about the impossibly over-burdened primary care visit—the unwieldy and unattainable expectations to assess quality metrics, HEDIS measures, preventative care, medication reconciliation, updates on health, vaccinations, family history, and allergies—and then to make sure that all of this is documented in the electronic health record (EHR). Each of these issues has its own important basis, to be sure, but their collective weight has done more than threaten the foundation of the primary care visit; it has broken it.

Overwhelmed clinicians cannot provide consistently meaningful care. Both caregivers and patients suffer. Burnout among caregivers is endemic. And patients experience not just the effects of medical errors, but the equally significant, unseen consequence of losing care—of knowing that their doctor has put together the unique pieces of their illness, of having been heard, of feeling compassion, of time.

Thinking is essential to our work. And “Thinking Time” is effectively a pause—a moment to take a breath, to step back, to ponder. If “Thinking Time” were to be mandated for primary care clinicians just as other metrics, what might that look like? Clinicians would have an incentive to do that which is most important—time to listen, consider the patient, the presentation, and to focus on diagnostic reasoning. That time would reduce the frequency of cognitive errors we make, and diminish the number of unnecessary tests we order, saving not only money but also the possible downstream complications of these procedures.

In 2008, The World Health Organization made a “time out” a component of their Universal Protocol for surgery. During this compulsory interval, members of the surgical team pause to review a checklist and confirm accurate patient identity, surgical site, and planned procedure. Just a decade later, it is difficult to imagine any medical procedure without this, and to consider the complications and errors that its absence engendered.

Required “Thinking Time” should become the primary care equivalent of a procedural “time out.” Such a pause would be a sustaining locus of care for both caregiver and recipient. A requirement that the components of this “Thinking Time” be documented in the medical record would strengthen the cognitive portion that was once its sole domain. As it once did, it would allow students and trainees to observe the now invisible course of diagnostic reasoning, to learn how doctors think.

When was I first in practice, requiring time to think would have seemed absurd; it was a given. And as a physician who bristles at all the current compulsory components of a visit, I am sad to find myself advocating to mandate yet another element. But the primary care appointment has been so thoroughly co-opted that its essential work has been made peripheral. A requirement is unfortunately necessary; what caregivers and patients need most must be put on a par with all the other visit metrics.

Curling provides “Thinking Time.” Healthcare should too. An expected, obligatory “Thinking Time” would provide a pause, a cognitive caesura. In poetry, this is the break between lines. In music, it’s taking a breath. In both of these settings, the caesura gives meaning to the words or sounds that surround it. Primary care needs this caesura desperately; we need a scheduled time to breathe. This breath will resuscitate caregiver and patient alike, and literally inspire and enable us to return that which is primary to primary care.